Basic Needs

To apply for assistance you MUST fill out the General Help Request Form below. If you do not your request cannot be honored.

New Program: We now offer gluten-free food to children and families in Massachusetts.
To request gluten-free food, please click here.

***THERE IS A LIMIT OF 4 ITEMS PER PERSON. PLEASE LIST ITEMS IN ORDER OF NEED.***

General Request

Page 1 of 4

Please complete the entire form—your request cannot be processed without all information!

Please choose your preferred pick up date*(mm/dd/yyyy)

Orders are ready one week from submission. If submitted on Friday, Saturday, or Sunday, they will be ready one week from Monday. You have 3 business days to pick up your order from the date it is ready.

First & Last Name*

Email*

Please ENTER A VALID EMAIL ADDRESS. You will receive an email confirmation.

Phone*

###

###

####

Address*

Note: Address information must match photo ID in order to pick up items

Building, Suite, Apt No.

City*

State*

Zip Code*

Photo ID Confirmation:*

By checking this box, I understand that a photo ID with the address listed above is required in order to pick up the items I requested.

If the photo ID does not match the info on this form, the order will not be released at the time of pick up.

Shelter or safe house

Number of adults needing items*

Number of children needing items*

Total number of people in household*

Previous

Next

Page 2 of 4

Request items for ADULTS

THERE IS A LIMIT OF 4 ITEMS PER PERSON. PLEASE LIST ITEMS IN ORDER OF NEED.

No ADULT items needed at this time.

Adult #1

Adult #2

Adult #3

Adult #4

Please specify

Male

Female

Previous

Next

Page 3 of 4

Request items for CHILDREN

THERE IS A LIMIT OF 4 ITEMS PER PERSON. PLEASE LIST ITEMS IN ORDER OF NEED.

Demographic Information (optional)This information is used for funding purposes only!Your answers will not impact the fulling of your order in any way (even if you choose not to complete it). The information gathered may help Project Just Because to receive grants to further benefit those in need. Thank you!

Ethnicity

African American/Black

Hispanic/Latino

Asian/Pacific Islander

American Indian/Alaskan

Caucasian/White

Other

If Other, please specify

Are you a veteran?

Yes

No

How did you hear about Project Just Because?

Please only click the Submit button once and be patient!Thank you!

If you currently live in a shelter or safe house, please list the name and contact info for the shelter/safe house.